What happened
On November 8, 2015, at approximately 10:45 UTC, a Cessna 188B agricultural aircraft, registration PT-WCK, was performing an aerial application mission near Jaguarão, Rio Grande do Sul. The aircraft was departing from an improvised runway at Granja Silvia.
Immediately after rotation, the aircraft experienced a sudden loss of lift, causing it to sink. During this descent, the aircraft struck a company support vehicle that was positioned approximately 20 meters past the runway threshold, directly in the takeoff path. Following the collision with the vehicle, the aircraft struck the ground. The aircraft sustained substantial damage, but the pilot escaped without injury.
The investigation
CENIPA investigators examined several factors regarding the takeoff performance and operational environment. While the pilot reported using 10 degrees of flap, investigators found the flaps were actually in the 0-degree position. This configuration likely increased the ground roll distance.
The investigation noted that the aircraft's takeoff roll reached 570 meters on a 600-meter runway, leaving almost no margin for error. Although the aircraft was within weight and balance limits, the investigation highlighted discrepancies in maintenance records, noting that certain inspections had exceeded their recommended intervals. Furthermore, the pilot admitted to not monitoring the airspeed indicator during the takeoff roll.
Investigators also scrutinized the operator's management, noting that the placement of the support vehicle in the takeoff path created a significant hazard. The investigation suggested that the operator's focus on economic viability over strict adherence to performance charts indicated a fragile safety culture.
Findings
- Inadequate flight planning, as the takeoff performance was operating at the very limits of the available runway length.
- Pilot judgment errors, specifically the failure to monitor the airspeed indicator and the use of a 0-degree flap setting which extended the ground roll.
- Inadequate managerial supervision, evidenced by the placement of an obstacle in the takeoff path and a lack of oversight regarding operational safety and maintenance record-keeping.
- Organizational culture issues related to the prioritization of operational efficiency over safety margins.